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Background: The aim of this study was to retrospectively evaluate the incidence and surgical outcomes of patients with native infective endocarditis (IE) and prosthetic aortic valve endocarditis (PVE) over the past decade at a single institution., Methods: Between January 2005 and December 2015, 289 patients (mean age, 63.3 ± 14.2 years) suffering from native IE (n = 186) and PVE (n = 103) of the aortic valve underwent surgical procedures. Perioperative data were acquired retrospectively for statistical analysis., Results: During the study period the mean incidence of endocarditis increased from 22.0 ± 4.2 (2005-2009) to 29.8 ± 10.1 (2010-2015) cases per year. In-hospital mortality was significantly increased in PVE (22.3%) versus IE (9.1%) patients (P < .001). In elective cases in-hospital mortality between the 2 groups was comparable (2.2% vs 4.6%; P = .288). Multivariate analysis identified urgent surgery (odds ratio [OR], 6.461; 95% CI, 1.941-21.509; P = .002), mitral regurgitation II (OR, 4.230; 95% CI, 1.249-14.331; P = .021), previous homograft operation (OR, 66.096; 95% CI, 2.369-1844.272; P = .0.14), and left ventricular ejection fraction < 40% (OR, 8.267; 95% CI, 1.931-35.388; P = .004) as independent risk factors for in-hospital mortality, whereas pathogen identification by preoperative blood cultures (OR, .228; 95% CI, 0.063-0.817; P = .023) was found to be independently protective., Conclusions: Surgery for native IE and PVE of the aortic valve may be performed with satisfactorily results at experienced cardiac surgical centers. In comparison PVE patients suffer from a more than twice as high in-hospital mortality, more postoperative complications, and inferior long-term survival. However preoperative identification of causative pathogens in IE and PVE allows for improved in-hospital survival., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Aims: In the current study we assess the impact of two different access-site suture-mediated closure devices (SMCD), ProGlide and Prostar, on vascular and bleeding complications after transfemoral transcatheter aortic valve implantation (TAVI), as well as on long-term mortality., Methods and Results: From 2008 to 2013, 1,022 patients underwent transfemoral TAVI in two German centres using ProGlide (n=506) and Prostar (n=516) SMCD to close the access site. The primary outcome was the incidence of peri-TAVI major vascular complications according to Valve Academic Research Consortium-2 (VARC-2) definitions. Secondary outcomes were the incidence of bleeding complications and mortality. Compared to the Prostar SMCD group, patients in the ProGlide SMCD group less frequently experienced VARC-2 major vascular complications (7.5% vs. 15.9%, p<0.001), closure device failure (0.8% vs. 2.3%, p=0.04), any bleeding (BARC: 36.8% vs. 53.9%, p<0.001; VARC-2: 30.8% vs. 34.9%, p=0.59). Furthermore, one-year mortality was significantly lower in the ProGlide SMCD group, 14.8% vs. 19.5% in the Prostar SMCD group, log-rank p=0.04. However, VARC-2 major vascular complications but not ProGlide use were identified as an independent predictor of one-year mortality (adjusted odds ratio 1.54, 95% CI: 1.01-2.34 and 1.01, 95% CI: 0.65-1.55, respectively)., Conclusions: In this analysis, the use of ProGlide SMCD was associated with a reduced risk of vascular and bleeding complications following TAVI compared to Prostar SMCD usage. However, major vascular complications but not ProGlide use did independently predict long-term mortality.

Background and Aim of the Study: The management of graft infection following ascending aortic replacement (AAR) and/or aortic valve replacement (AVR) with destruction of the root remains a challenge. Besides technical issues, the choice of graft material is controversial. The study aim was to investigate the initial results of aortic root replacement (ARR) as redo-surgery for infection using the xenopericardial all-biologic conduit (BioIntegral) as an alternative to a homograft or prosthetic material., Methods: Between February 2013 and January 2015, a total of 18 consecutive patients (16 males, two females; mean age 61 ± 14 years) were reoperated on for infection at a mean of 55 ± 61 months (range: 3 to 219 months) following previous AVR (n = 6), supracoronary aortic replacement (SAR, n = 2), AVR + SAR (n = 1), root replacement (n = 7), and root reconstruction (n = 2). Two patients (11%) had undergone more than one previous cardiac operation. Signs of infection were seen on computed tomography (CT) scanning in 17 patients (94%). Additional 18F-FDG PET-CT was performed in nine patients (50%)., Results: The cardiopulmonary bypass and crossclamp were 289 ± 77 min and 187 ± 59 min, respectively. Hypothermic circulatory arrest (HCA) + selective antegrade cerebral perfusion (SACP) was necessary in nine patients (50%) and concomitant procedures in 11 (61%). Postcardiotomy extracorporeal life support (ECLS) was necessary in five patients, and renal replacement therapy in eight. One patient died intraoperatively, and the overall 30-day mortality was 22% (n = 4) secondary to multi-organ failure. Risk factors for mortality were myocardial failure requiring ECLS (p = 0.02) and the need for root replacement following previous isolated AVR (p = 0.05). The mean follow up was 12 ± 5 months. Early graft reinfection occurred in one patient (6%), and another presented with pleural empyema without evidence of persisting conduit infection. Thus, freedom from graft reinfection was 94%. No case of structural valve deterioration was seen., Conclusions: Aortic root replacement using a xenopericardial conduit in patients with graft infection is technically feasible. Hemodynamics and surgical handling are comparable to that of homografts, but the off-the-shelf availability favors this approach. Mortality was substantial but comparable to that of other series and grafts, with low reinfection rates. Long-term outcome regarding the eradication of infection and durability of the graft remains to be demonstrated.

Background and Aim of the Study: With the changing age structure of the population, cardiothoracic surgeons must deal with an increasing number of patients suffering from degenerative valve disease. Septuagenarians with triple valve disease may be refused surgery due to a potentially high perioperative risk related to co-morbidities. The study aim was to elucidate the indications and compare outcome, with a focus on age-related mortality and morbidity., Methods: Between December 1996 and July 2010, a total of 90 consecutive patients (45 males, 45 females; mean age 68 +/- 9 years; logistic EuroSCORE 21 +/- 16%) underwent triple-valve surgery at Hannover Medical School. Of these patients, 70% had degenerative disease, 19% endocarditis, and 11% a rheumatic cause, while 24% underwent cardiac redo-surgery. For further analysis, the cohort was divided into two groups according to age: < or = 70 years (n=44) and >70 years (n=46). The follow up was performed according to current guidelines for reporting mortality and morbidity after cardiac valve interventions, including a quality of life assessment (Minnesota Living With Heart Failure Questionnaire; MLHFQ)., Results: Mortality among the patients was 16%, 24%, and 26% at 30, 60, and 90 days, respectively. The one-year survival was 69% for the whole cohort, and no difference was seen between the age groups. Follow up (mean 46 months) was complete in 96% of all patients who survived at least three months (n=67). Valve-related morbidity was low in both groups, with predominantly a recurrence of tricuspid insufficiency. The MLHFQ score was similar in both groups., Conclusion: Triple-valve surgery is associated with a high perioperative risk. However, the acceptance of elderly patients for this surgery is not associated with a higher mortality or valve-related morbidity. The patients' quality of life was acceptable during follow up, and not affected by age. Hence, the refusal of surgery should depend not on old age alone but rather on an individualized assessment of the patient.

Objective: In patients with symptomatic aortic valve stenosis and a high estimated operative risk due to previous coronary artery bypass grafting (CABG) procedures, interventional aortic valve implantation techniques may ultimately prove superior. However, recent studies have revealed increased mortality and impaired survival in patients with concomitant coronary artery disease (CAD)., Methods: Between January 1996 and May 2010, 60 patients (73 ± 6 years, 15 female (25%)) underwent conventional operation 9 ± 6 years after CABG for symptomatic aortic valve stenosis (European System for Cardiac Operative Risk Evaluation, EuroSCORE) standard 11 ± 3%, logistic 27 ± 17%, Society of Thoracic Surgeons (STS) Score 19 ± 8%). Coronary angiography revealed open grafts and no need for further revascularization in all patients. High-risk patients were identified (log. EuroSCORE≥ 20%, n = 34) and divided by age (< 75 years, n=15; ≥ 75 years, n=19) for sub-group analysis. Follow-up for all 60 patients was performed according to the current guidelines: quality of life was assessed using the Minnesota Living with Heart Failure Questionnaire (MLHFQ)., Results: Thirty-day-mortality was 5% (n=3). During follow-up (100% complete), 18 patients died. Thus, 1-, 3- and 5-year survival was 91%, 77%, and 69%, respectively. No differences in survival could be detected between the two high-risk groups. Quality of life revealed excellent results for the entire cohort, as well as both high-risk groups., Conclusions: Conventional surgery in patients with symptomatic aortic valve stenosis after previous CABG can be performed with excellent results despite a high calculated risk, independent of age. Although conventional surgery is technically more demanding and associated with substantial surgical trauma, it is justified by the excellent survival and high quality of life in this high-risk patient cohort., (Copyright © 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Background and Aim of the Study: It is well known that aortic root re-replacement presents a formidable technical challenge. Thus, the study aim was to describe the authors' experience with this high-risk cohort., Methods: Between August 1996 and January 2009, a total of 26 patients (mean age 51 years; range: 16-72 years) underwent aortic root re-replacement surgery at the authors' institution. Previous aortic root operations included mechanical valved conduit (n = 9), tissue valved conduit (n = 5), Ross procedure (n = 4), homograft (n = 4), David procedure (n = 2) and Yacoub procedure (n = 2). The indications for surgery included endocarditis (n = 16), Ross procedure failure (n = 4), valve degeneration (n = 3), anastomotic aneurysm (n = 2), and severe valve insufficiency (n = 1)., Results: The reoperations performed were classified as follows: aortic homograft (n = 11), mechanical conduit (n = 9), tissue valved conduit (n = 4) and David procedure (n = 2). The mean cardiopulmonary bypass time was 219 min (range: 101-398 min), and the mean cross-clamp time 142 min (range: 89-253 min). The mean ICU stay was 8 days (range: 1-45 days), and the mean hospital stay 20 days (range: 3-64 days). Four rethoracotomies were performed for postoperative bleeding or tamponade (14%). Two patients (8%) died within 30 days of surgery, and three (12%) required pacemaker implantation due to atrioventricular block (grade III)., Conclusion: Aortic root reoperation, even in the setting of endocarditis, can be carried out with excellent results. The major goals of this concept include a clinical examination and preoperative diagnosis, in addition to computed tomography to identify possible pitfalls during re-sternotomy. Care must also be taken to provide adequate myocardial and organ protection, by utilizing blood cardioplegia and individual selective perfusion techniques.

The objective of this study was to compare the results of elective composite (C) vs. David (D) operations in patients requiring additional aortic arch surgery using hypothermic circulatory arrest (HCA) and selective antegrade cerebral perfusion (SACP), with the focus on postoperative neurological outcome and quality of life (SF-36). Between November 1999 and March 2006, 333 patients underwent aortic root surgery and ascending aortic replacement with HCA and SACP at our institution. Out of these patients, 46 were matched with respect to age, gender, HCA-time and year of surgery. Two patients, one in each group, died during hospital stay (4%), with no late deaths. Follow-up was completed in 95% [64 (6-90) months]. Cardiopulmonary bypass (CPB) time (141 min vs. 168 min, P=0.007) and aortic cross-clamp time (99 min vs. 123 min, P=0.004) were significantly longer in the David-group. The incidence of temporary neurological dysfunction (TND 7%: D n=1, C n=2) was not different between groups, no permanent dysfunction could be detected. Follow-up SF-36 scores were comparable. The combination of aortic arch surgery with more time consuming valve sparing aortic root surgery does not increase the risk for adverse outcome applying comparable periods of HCA and SACP.

OBJECTIVES Aortic valved allografts (homografts) have been used alternatively to mechanical or biological valve prostheses in expectation of better durability; however, homograft valves do degenerate, and redo procedures have proven challenging due to heavy wall calcification. The aim of the study was to compare the outcome of open surgical (SAVR) and transcatheter aortic valve replacement (TAVR) in degenerated homografts. METHODS Between 1993 and 2022, 81 patients underwent repeat aortic valve procedures having previously received an aortic homograft. The redo had become necessary due to regurgitation in 85% and stenosis in 15%. Sixty-five percent underwent open surgery, 35% TAVR. RESULTS Isolated SAVR was possible in 79%, and root procedures were necessary in 21%. TAVR was performed in 79% via transfemoral and 21% via transapical access. Median prosthetic valve size was 23 (22.3–23.2) mm in the SAVR and 26 (25.2–26.9) in the TAVR group. Thirty-day mortality was 0% in the TAVR and 7% in the SAVR group (P  = n.s.). TAVR showed a significantly better outcome concerning prolonged ventilation (0 vs 21%, P  = 0.013) as well as ICU (1 vs 2 days; P  < 0.001) and in-hospital stay (10.5 vs 13 days; P  = 0.028). Five-year survival was statistically comparable between groups, and no severe leakage was observed. CONCLUSIONS SAVR following structural homograft degeneration shows acceptable results, but the perioperative risk remains substantial and poorly predictable. TAVR presents a reasonable and more easily accessible alternative and is associated with good short- and mid-term results. In the absence of relevant contraindications, TAVR is presently the preferred treatment option for these patients at our center. [ABSTRACT FROM AUTHOR]

The choice of graft material for the restoration of the aortic root has long been a matter of debate. Repeat aortic valve replacement for failing aortic root homograft. Redo aortic valve replacement following root replacement with a homograft: open surgery or TAVI?. [Extracted from the article]

Background Clinical relevant cerebrovascular events (CVE) following transcatheter aortic valve implantation (TAVI) still remain a devastating complication associated with mortality and severe impairments. Therefore, identification of particularly modifiable predictors of this complication is clinically relevant and an important step for planning preventive strategies. Methods A total of 985 patients who underwent trans-femoral TAVI for aortic valve stenosis in our institution from February 2008 to January 2015 were considered. The influence of demographics, clinical and procedural data on the occurrence of CVE was assessed with a competing risk model with death as competing event. Clinical events were defined according to VARC-2 criteria. Results At a median follow-up of 838 days, 95% CI 807–892, 59 patients experienced any CVE (5.9%) and the overall cumulative mortality rate was 46.1%. CVEs mainly occur later than 30 days after TAVI (47.5%), 88.1% of them were of ischemic origin and 52.5% were disabling events. Independent predictors of CVEs were age (hazard ratio 1.05; 95% CI 1.01 to 1.09), history of CVE (hazard ratio 2.54; 95% CI 1.39 to 4.63) and use of balloon post-dilation (hazard ratio 1.85; 95% CI 1.08 to 3.18). Conclusion In patients undergoing TAVI incidence of clinically relevant CVEs is frequent with half of the events occurring after the first 30 days post-TAVI. Identification of balloon post-dilation as the only modifiable predictor of CVE risk at mid-term, urges its cautious performance after prosthesis implantation. ClinicalTrials.gov identifier NCT02289339. [ABSTRACT FROM AUTHOR]